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Addendum: for use with Pennsylvania Health online ExamFX courses and study guide version 20534en, per exam content outline updates effective July 1, 2017. 

The following are content additions to supplement your existing text unless otherwise indicated:

Medical Plans

1. Pennsylvania Mandated Benefits (Individual and Group)

Medical Foods – new section

Healthcare insurers must provide benefits for the costs of nutritional supplements, otherwise known as formulas. Supplements must be medically necessary for the treatment of rare hereditary genetic metabolic disorders.

Health insurers must also provide coverage for infants and children requiring a medically necessary amino acid-based elemental medical formula for the treatment of the following health conditions:

• Food protein allergies;
• Food protein-induced enterocolitis syndrome;
• Eosinophilic disorders; and
• Short-bowel syndrome.

Benefits for nutritional supplements may be subject to the same copayments and coinsurance provisions as any other medical services covered under a health insurance policy. However, they are exempt from deductible provisions. The exemptions must be explicitly provided for in the policy. Coverage for supplements is not required if the insured is currently employed outside of the Commonwealth or if the insured's employer provides insurance as an employment benefit.

Orally Administered Chemotherapy Medication – new section

Health insurance policies must provide coverage on the same favorable basis to orally administered chemotherapy medication as it would for intravenously administered or injected chemotherapy medications. Chemotherapy medication means a medication prescribed by a treating health care practitioner that is necessary to kill or slow the growth of cancerous cells. Cost sharing for chemotherapy mediations may be increased, as long as it is applied generally to other medical or pharmaceutical benefits administered in a similar health care setting under the contract.

Mental Health Parity and Addiction Equity – new section

The Affordable Care Act enacted rules on how health insurance issuers carry out the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA stipulates that the financial requirements (such as coinsurance) and treatment limitations imposed on mental health and substance use disorder benefits cannot be more restrictive than the requirements and treatment limitations that apply to all other medical and surgical benefits.

The MHPAEA categorizes benefits into 6 classifications to determine parity. If medical/surgical benefits are provided, the policy must also provide the same standards to mental health and substance abuse. The 6 classifications include:

1. Inpatient in-network;
2. Inpatient out-of-network;
3. Outpatient in-network;
4. Outpatient out-of-network;
5. Emergency care; and
6. Prescription drugs.

Addendum: for use with Pennsylvania Property and Casualty online ExamFX courses and study guide version 20582en and 20583en, per exam content outline updates effective July 1, 2017. 

The following are content additions to supplement your existing text unless otherwise indicated:

Dwelling Policy

1. Conditions and Definitions – additions per 2014 Dwelling (DP) ISO Form

Deductible

Unless otherwise noted, in regards to any one loss:

• The insurer will pay only the part of the total of all loss payable that exceeds the deductible shown in the Declarations; and
• If two or more deductibles apply to the loss, only the high deductible will apply.

Concealment or Fraud

Coverage will not be provided to any insured if one or more persons has intentionally concealed or misrepresented a material fact relating to the insurance, has made false statements relating to the insurance, or has engaged in a fraudulent conduct.

Duties After a Loss

Duties After Loss – In case of a loss to covered property, the insurer has no duty to provide coverage under the policy unless the insured complies with the following duties:

1. Give prompt notice to the insurer or its agent;
2. Protect the property from further damage; if repairs are required, the insured must make reasonable and necessary repairs to protect the property, and keep an accurate record of repair expenses;
3. Cooperate the insurer in the investigation of the claim;
4. Prepare an inventory of the damaged personal property, showing the quantity, description, actual cash value and amount of the loss;
5. Show the damaged property, provide records and documents and submit to examination under oath, while not in the presence of another insured, and sign the same; and
6. Send to the insurer, within 60 days, a signed, sworn proof of loss.

Appraisal

If there is a disagreement between the insured and the insurer on the amount of the loss, either party can make a written demand for an appraisal. Each party will select a competent and impartial appraiser within 20 days after receiving a written request from the other party. The two appraisers will then select an umpire. If they cannot agree upon an umpire within 15 days, the insurer and the insured may request that the choice be made by a judge of a court of record in the state where the property is located.

Note that each part must pay its own appraiser and bear any other expenses of the appraisal and umpire equally.

Suit against the Insurer

Suit against the insurer — No suit may be brought against the insurer unless the insured has fully complied with all policy conditions and the action is started within 2 years (24 months) of the date of the loss.

Casualty Insurance Basics

1. Pennsylvania Laws, Regulations, and Required Provisions
2. Cancellation and Nonrenewal

Private Residential – addition to section

In the event an insurer has reason to believe the policyowner is unable to read the notice, the insurer must provide a notice is an appropriate foreign language equivalent or oral communication in a language understood by the policyholder.

In the event the insured disagrees with the insurer regarding cancellation or nonrenewal, the insured may appeal the action by providing a written request for an administrative hearing to the Department. Both parties may submit written comments for consideration by the Insurance Commissioner. Upon completion of the hearing, the Commissioner will issue an order with the findings.

Auto Insurance

1. Laws
2. Cancellation/Nonrenewal

Grounds – additions to existing list

Prohibited grounds to cancel or refuse to issue or renew include the following:

• Residence or location of operated vehicle;
• No more than two moving violations during a 24-month period, resulting in the insured bearing five points or less;
• Accidents occurring while an automobile is lawfully parked;
• Accidents where the applicant or owner was reimbursed by the person responsible;
• Any accident where the automobile is struck in the rear and the owner wasn't convicted of a moving traffic violation;
• Any accident that's a result of a hit-and-run, which has been reported to the proper authorities within 24 hours;
• Accidents resulting from animals, fowls, flying gravel, missiles or falling objects;
• Accidents resulting from emergency response, applicable to volunteer members of police, fire, first aid squad, or any law enforcement agency;
• A result of the prior agent associated with the policy being terminated, unless the decision would have been made had the relationship continued.

Commercial Package Policy

1. Commercial Crime – changes per 2015 Commercial Crime ISO Form
2. Exclusions –additions to the existing list

Common policy provisions applicable to crime coverage forms (both discovery and loss sustained) specify the following general exclusions:

• Data security breach: Fees, costs, fines, penalties and other expenses incurred by the insured which are related to the access to or disclosure of another person's or organization's confidential information; and
• Virtual currency: Loss involving virtual currently of any kind (e.g. digital currency, crytocurrency, or any other type of electronic currency).